Assisted Housing Complexes

Managed by Human Resource Development and Employment, Inc.

STUDENT QUESTIONNAIRE

Applicant ______Date______

TO BE COMPLETED BY APPLICANT YesNo

1)Are you a full-time student?

2)Are you a part-time student?

If you answered yes, the owner/agent is required to determine your eligibility as a student. You may refer to the tenant selection plan for additional information regarding student eligibility. Please complete the following questions:

YesNo

3)Are you old enough to execute a lease?

4)Have you lived separate from your parents for at lease one year?

If yes, proceed to question 5 . If no, you may still be eligible for assistance. Please answer the following questions:

a)Are you at least 24 or will you be 24 by December 31 of this year?

b)Were you an orphan or ward of the court through the age of 18?

c)Are you a veteran of the U.S. Armed Forces?

d)Do you have legal dependents other than a spouse (i.e. dependent children)?

e)Are you a graduate or professional student?

f)Are you married?

g)Are your parents receiving or eligible to receive Section 8 assistance?

5)Have your parents claimed you as a dependent on their most recent tax return?

If you answered No, please provide your parent’s contact information so that we may verify:

Parent 1 Name
Address 1
Address 2
City, State, Zip
Parent 2 Name
Address 1 / Same as above
Address 2
City, State, Zip

YesNo

Are you receiving any financial assistance, from anyone outside the household,

to pay for your education?

If so – Please list all sources of financial assistance including the school, any providers of scholarships or grants, parents, associations, etc.

______

______

______

______

______

PENALTIES FOR MISUSING THIS FORM
Title 18, Section 1001 of the U.S. Code states that a person is guilty of a felony for knowingly and willingly making false or fraudulent statements to any department of the United States Government, HUD, the PHA and any owner (or any employee of HUD, the PHA or the owner) may be subject to penalties for unauthorized disclosures or improper uses of information collected based on the consent form. Use of the information collected based on this verification form is restricted to the purposes cited above. Any person who knowingly or willfully requests, obtains or discloses any information under false pretenses concerning an applicant or participant may be subject to a misdemeanor and fined not more than $5,000. Any applicant or participant affected by negligent disclosure of information may bring civil action for damages, and seek other relief, as may be appropriate, against the officer or employee of HUD, the PHA or the owner responsible for the unauthorized disclosure or improper use. Penalty provisions for misusing the social security number are contained in the Social Security Act at 208 (a) (6), (7) and (8). Violation of these provisions are cited as violations of 42 U.S.C.408 (a) (6), (7) and (8).

Print Name______

Signature______

Date______


HRDE-A13 Student Questionnaire